Cancellation Form by x8SE33


									                                  Faculty/Staff Membership Cancellation Form
University ID#:                                               Date:

Name:                                                                                              Office Use Only

Department:                                                                                                          Date   Initial
                                                                                                   Form Received
Address:                                                                                           CREC Updated
Email:                              Home or Campus Ph:                                             PD Stopped
                                                                                                   Info Entered
Desired Date of Cancellation:

Reason for Cancellation: (please specify)

    Non Usage        Relocation       Financial         Medical            Joined other Facility

         Other(please specify)

Please provide us with feedback regarding your experience with the Student Recreation Center

Cancellation Terms:
Membership fees are non-refundable except in cases of physician-verified illness, a move out of the 50-mile radius of UNCG,
employment termination or unless cancelled within three days of purchase. Membership cancellation notification must be
submitted in writing on the Cancellation Form and must be received by Campus Recreation by the 10 of the month prior to the
desired cancellation month. Cancellation during an initial one-year contract period will only be permitted in cases of physician-
verified illness, a move out of the 50-mile radius from UNCG, or employment termination.

Member Signature:                                                                        Date:

Return completed Cancellation Form to:
UNCG Campus Recreation, 422 Student Rec Center, 1510 Walker Ave, Greensboro, NC 27412
Fax to 336.334.4017 or by email to

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